October 12,2014

22:23



The Ebola Virus...Image courtesy of scienceblogs.com

It's bad enough that a fellow from Liberia by the name of Thomas Eric Duncan through hubris, stupidity, or simply bad luck brought Ebola to our shores. He did ultimately seek medical attention in the Emergency Room of Texas Health Presbyterian Hospital in Dallas when he became symptomatic with the characteristic fever and pain of an Ebola infection. In fact, he presented twice to the Dallas ER. In between his two visits, Mr. Duncan was set loose on a city of well over a million souls while his disease was at its most infectious level. (He has since died of the disease, and sadly, one of the nurses who cared for him now has it. Let us pray for her speedy recovery.) How could this breach of public health have happened? It seems to have something to do with IT, specifically, the configuration of the hospital's EHR.

CNBC quotes Jonathan Bush (as it turns out, Jonathan is the nephew and cousin of the former Presidents...hat tip to Ranjan), head of Athenahealth:
The failure of a Dallas hospital's electronic medical record system to flag a man who turned out to be infected with the Ebola virus underscores how clunky, outdated and inefficient health information systems typically are in the U.S., a medical IT CEO charged Friday.

"The worst supply chain in our society is the health information supply chain," said Bush. . . "It's just a wonderfully poignant example, reminder of how disconnected our health-care system is."

"It's just a very Stone-Age sector, because it's very conservative," Bush said. "Hospital health care is still in the era of pre-Internet software."

"The hyperbole should not be directed at Epic or those guys at Health Texas," Bush said. "The hyperbole has to be directed at the fact that health care is islands of information trying to separately manage a massively complex network . . . People trying to recreate their own micro-Internet inside their own little biosphere . . . that'll never, never, never be excellent," Bush said. "There's no 'network effect' in health care today."
How does this apply to Mr. Duncan unleashing Ebola in the heart of Texas?
The hospital Thursday night said when Duncan was first examined Sept. 25 by a nurse, he was asked a series of questions, including whether he had traveled outside of the U.S. in the prior month.

"He said that he had been in Africa," the hospital said in a statement. "The nurse entered that information in the nursing portion of the electronic medical record."

But it turns out that answer—which could have alerted doctors of the possibility Duncan had Ebola—was not relayed electronically to them because of "a flaw" in the way doctors' workflow portions of the electronic health records interacts with the nursing portions of the EHR.

"In our electronic health records, there are separate physician and nursing workflows," the hospital said. "The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician's standard workflow."
Of course, that particular problem at that particular hospital is now fixed. But . . .
"We have made this change to increase the visibility and documentation of the travel question in order to alert all providers," Texas Health said. " We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola."

Bush noted that typically when problems like the flaw in Texas Health's EHR system are fixed, "they're fixed only at the place where they appeared."

"Those mistakes are happening constantly," Bush said.

But, "philosophically I think hospitals should get out of the business of trying to program computer systems, and expand in the business of treating patients. But that's a standard thing that goes wrong with millions of configurations" of EHRs, he said.
Mr. Bush was quite tactful, but the implication of his statement is truly astounding. He is saying, perhaps not quite in so many words, that the IT department of the Texas Health hospital in Dallas, by poorly implementing (my opinion, not necessarily his) poorly designed (again, my opinion, not necessarily his) software, could be responsible for a disaster. This glitch has potentially allowed Ebola to spread further than it would have had Mr. Duncan been put immediately into confinement upon his first presentation. To be fair, the patient had been in contact with others before his first ER trip; still, we can assume he had more interaction with more people than he might have otherwise. We can only wait and see how many of his family members and acquaintences come down with the often-fatal disease. I should also mention that the ER physician should probably have thought to ask about foreign travel when presented with a feverish African national presumably speaking with an accent.

There is much online about Epic, Presby's EHR provider. Google will supply link after link after link if you so desire. There are several take-away messages: Epic has severe interconnectivity / interoperability problems, and it is a HUGE political player, with its founder Judith Faulkner being quite the Obama supporter. Faulkner, and Epic employees, have given millions to Mr. Obama and other Democratic causes. Epic has received significant federal subsidy money, and it is up for an $11 Billion government contract. Michelle Malkin also reports that:
Faulkner, an influential Obama campaign finance bundler, served as an adviser to David Blumenthal. He’s the White House health information technology guru in charge of dispensing the federal electronic medical records subsidies that Faulkner pushed President Obama to adopt. Faulkner also served on the same committee Blumenthal chaired.

Cozy arrangement, that.
I'm straying a little off-topic here, but I think it is unlikely in the extreme that Epic will shoulder even the slightest blame for Mr. Duncan's Dallas destruction. After all, as we say in the trade, PBKAC, Problem (was) Between Keyboard and Chair. In other words, it wasn't Epic's fault that whatever IT employee or committee failed to connect the dots and the map the critical foreign travel field from the  nurses' intake screen to the doctors' review screen. Oops. So sorry.

Personally, for what little it's worth, I do NOT let Epic, or any other software company, off the hook quite so easily, nor do I bow to the IT departments which often control such software but don't grasp the criticality of the workflow they are now governing, let alone the workflow itself.

I've ranted for pages and pages about image sharing, and how it is malpractice for patient images to be essentially held hostage by the IT and other administrative types who are adamant that the competing hospital across town (or across the street) will NEVER EVER be allowed to touch their precious data. And I've yowled and whined about PACS software that was clearly NOT written for use by any practicing radiologist I've ever met.

Please indulge me while I add to these rants.

I had the occasion to accompany Mrs. Dalai to her annual (8 years postponed) internist visit. Her doc showed me how much fun it is NOT to order something as simple as a PA and Lateral CXR in our illustrious EMR's bilious CPOE (Computerized Physician Order Entry) system. It is a complete miracle that any order at all is entered correctly in this absolute abortion of an interface, and I'm not at all surprised when the wrong order comes through for the wrong indication. The electronic chart function isn't any better. Finding a particular lab value can be an exercise in agony (akin to using some PACS I can name) and it just goes downhill from there. When I asked around to find out who OK'd this particular piece of garbage, I was met with shrugs and silence.

Do you sense a familiar refrain? (Lawyers please note...THIS IS ALL MY VERY OWN HUMBLE OPINION, as is every other word that I have ever written or ever will write, unless quoted from someone else, and worth every cent my dear readers paid for it.) Once again, here in the Health Care Field of Dreams, we have badly written, badly designed software, created with minimal input from those who have to use it, selected and then implemented by IT types who also don't have to use it and don't understand enough about those who do to get it done right. This has to stop. Right. Bloody. Now. Hit CNTL-ALT-Delete and start over.

With Epic and the government having their hands deep inside each others' panties, we may well be stuck with these unusable systems for the foreseeable future. (And as an aside, if you deconstruct the Meaningful Use rewards and penalties, doctors are being bribed to buy EHR's that have the certified and confirmed ability to transmit data to Washington, D.C., so again, we won't expect the government to do anything about anything.) But, the demise of Mr. Duncan, and no doubt dozens if not hundreds more that he inadvertently infected between his two ER visits may level the playing field.

It is clear that Epic's epic Dallas fail (which might not really be totally attributable to Epic per se, but rather to the way the product was set up in the field, not passing that one lil' bitty critical entry to where it should go), contributed to Mr. Duncan's being released when he should have been locked up in the local version of Wildfire. It is possible, just barely possible, that this tragic episode will awaken the public to the dangers inherent in the IT-controlled medical software industry and its acronymbysmal spawn, EHR's, CPOE's, and the occasional unruly PACS. Get enough people upset about this, and they will call their congressmen, and more importantly their lawyers. (I would submit that more gets done by class-action suit in this country than by Congress.)

I realize that replacing these huge legacy systems which were outdated before they were even conceived would cost somewhere in the trillions of dollars, and so I'm not holding my breath that this will ever happen. But maybe a few million and billion dollar suits and fines would get the attention of the Epics, the Cerners, McKessons, and all the others who create these nightmares. Or maybe, just maybe, the execs will read this, and the other rebellious propaganda we are starting to see online, and realize that they are causing damage rather than progress, and be inspired to turn it all around. I'm a staunch believer in the electronic record, PACS, computers, iPhones, Apple Watches, and anything else technical. This is the future, without question. But it has to be done right, and so far that hasn't happened.

We can hope that the late Mr. Duncan can accomplish in death what no one has yet been able to manage while alive.  We can hope, anyway...

October 11,2014

22:04
What may seem obvious to some can be mysterious to others. Case in point: the introduction of Western-style toilets to parts of China. It was necessary to provide pictographic instructions to be sure the new equipment was utilized properly:


Assuming you have flown on a commercial airliner ever in your life, you've had to sit through what some would consider an equally-foolish instruction set: the safety briefing. This is how you buckle your seat belt, if the plane goes down somewhere it shouldn't, find the closest exit unless said exit is under water, in which case you should go elsewhere. And of course, if the oxygen masks should drop, grab them all for yourself and don't let anyone else have one unless they pay you a lot of money before they pass out.

In years past, we passengers have had no other entertainment during the safety spiel except for the airline magazine, and SkyMall catalog, and those get old fast. But about a year ago, the FAA allowed us to have our small personal electronic devices on during take-off and landing. And so, many of us have our phones or tablets running at all times, in Airplane Mode of course, playing Candy Crush while the frustrated flight attendants drone on about the unlikely possibility of a water landing on a trans-oceanic flight.

The flight attendants are not pleased about this. From the Wall Street Journal:
Lawyers for the nation’s largest flight-attendant union argued in federal court Friday to effectively reinstate a government ban on the use of electronic devices during takeoffs and landings.

The Association of Flight Attendants-CWA is suing the Federal Aviation Administration, saying the agency notice last year that paved the way for fliers to use their devices throughout flights violated federal regulations that require passengers to stow all items during takeoffs and landings.

Justice Department lawyers representing the FAA say the agency’s guidance, which permitted fliers to keep smaller devices in their hands during all phases of flight, doesn’t violate the stowage rule because small devices aren’t governed by it. The two sides argued the case Friday to a three-judge panel with the U.S. Court of Appeals for the D.C. Circuit. . .

Attorney Amanda Duré, who is representing the attendants union, said that since the policy change, many fliers have stopped listening to attendants’ emergency announcements and, in at least one incident, a tablet became a projectile during turbulence. The union also is concerned the devices could impede passengers’ exit from an aircraft during an emergency.
ONE tablet flew, and we have to take everyone's away. How do we know it wasn't thrown?

I have great respect for flight attendants. They don't have an easy job, and they have to deal with throngs of humanity, some of whom are more accustomed to the joys of Greyhound than The Friendly Skies. I remember the days when stewardesses (can I still use that term?) were all female, 22 years old and coiffed to the nines. This is no longer the case, for better or worse. But with the demise of "coffee, tea, or me," an element of customer service has gone by the wayside. There is at least a faint edge to the attitude of many attendants today, and downward spirals ala Alec Baldwin are not unheard of. I personally think the suit against the FAA is mostly a temper-tantrum, lashing out at the passengers who are now even more contemptuously ignoring the boring lecture that in a panic situation they would all forget anyway.

This adversarial situation does not have to continue. A little thinking outside the box, or at least inside a different box, could provide a very easy fix. It's time for the airlines to take a page from Disney's book. The Disney people know crowd control and safety better than most any other operation out there. I'm sure most of you have been to Disney World, or Disneyland, and thus you've been a passenger on Star Tours and the old Body Wars. While waiting the better part of a day for your 5 minutes on the ride, Disney entertains with various props and videos. In fact, just before boarding your StarFarter 2000, you will be shown this video:



As with comedy, it's all in the timing. . . We are all captive in the gate area while waiting to board the plane, and also while standing in line on the jetway while waiting on Ma and Pa Kettle to jam their entire life's possessions into the overhead bin. THIS is the time to show the safety video on strategically placed monitors! Make them funny, as Delta has started to do lately, and the message will get across far better than it does under the present system. Trust me and Disney, this will work!!!!

Here's one of the new Delta safety videos for your viewing pleasure:



If you think this might work, let the FAA and the airlines know your opinion. But please don't mention my name. I have some traveling to do, and I don't want to be the target of angry flight attendants. It seems they have some secret approaches to revenge:

1. Coded hand gestures
Flight attendants "employ all sorts of unofficial methods and codes" to deal with difficult fliers, reports Emma Messenger at the Daily Mail. A "subtle wag of a finger" behind someone's head means that he's lecherous and may get handsy (or worse) with the staff. To alert colleagues that a passenger is drunk, attendants cross their fingers over the hospitality cart.

2. High winds
At the end of a demanding flight, writes David Sedaris in The New Yorker, some attendants indulge in the peevish practice of "cropdusting" — silently passing wind as they walk down the aisle making their final checks. "Reclined in their seats, heads lolling to the side ... airplane passengers are prime fart targets," comments Maureen O'Connor at Gawker.

3. Dirty drinks
Ellen Simonette — author of Diary of a Dysfunctional Flight Attendant: The Queen of Sky Blog — reminisces in The New York Times about the time a colleague took revenge on a loudmouthed passenger by making him "a very special drink" in the privacy of the galley, rubbing the rim of his glass on the plane's "filthy floor" before serving it up with a "devious smile."

4. Abusing their powers
We've all seen the seat-belt sign light up in midflight, though there isn't a hint of turbulence. Blame your attendants, says the Daily Mail's Messenger, who often switch it on so they can "have a nice cup of tea and gossip in peace."

5. Starting a blog
Countless flight attendants vent about passengers by blogging anonymously. Dubai-based blogger Tampax Towers recently railed against fliers who hold up security lines by wearing metal-studded jeans, while, over at These Wings Talk, a catty account of an experience with a "One-Eyed Cyclops Passenger" makes for surprising reading.
Coffee, Tea, or Dalai?

September 26,2014

11:32
Dalai's note:  A piece by Dr. Richard Gunderman posted on TheHealthcareBlog.com.  It is unclear whether or not Dr. Gunderman's "discovery" is a real document or not. Still, it would seem to explain a lot of what we are seeing in healthcare today...

How To Discourage a Doctor

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a healthcare consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said.

“The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff.

“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff.

“Transforming previously independent physicians into employees has increased hospital influence over their decision making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic initiatives. But physicians have invested many years in learning their craft, they hold their professional autonomy in high esteem, and they take seriously the considerable respect and trust with which many patients still regard them. As a result, the challenge of managing a hospital medical staff continues to resemble herding cats.

“Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus.

“How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following:

“Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently.

“Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation “at risk,” so that physicians begin to feel beholden to hospital administration for what they manage to eke out.

“Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidence based. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures.

“Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher, from the 75th “Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness,” a growing sense among physicians that whatever they do, they cannot meaningfully influence healthcare, which is to say the operations of the hospital.

“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control. When physicians think about the work they do, the first image that comes to mind should be the hospital, and when patients realize they need care, they should turn first to the hospital, not a particular physician. One effective technique is to ensure that patient-physician relationships are frequently disrupted, so that the hospital remains the one constant. Another is. . . .”

The sound of a door roused me again. The man in the three-piece suit emerged from the office, he and the hospital executive to whom he had been speaking shaking hands and smiling. As he turned, I looked about. Where was “How to Discourage a Doctor?” It was not on the table, nor was it on the chair where I had first found it. “Will he think I took it?” I wondered. But instead of stopping to look for it, he simply walked out of the office. As I watched him go, one thing became clear: having read that document, I suddenly felt a lot less discouraged.

October 23,2014

9:06

World Series: SF GiantsDuring this tech boom, is it a coincidence that the tech savvy San Francisco Giants are in the World Series for the third time since 2010? In this post, we take a look at the relationship of technology, leadership, big data analytics, and baseball. In particular, we explore how Major League Baseball manages its player/patient population, and the trends they are following since converting players from paper medical records to EHR.

The New Frontier in Baseball Data: Medical Analysis and Injury Prevention

Baseball teams are very secretive about how they use their data. Teams, like the San Francisco Giants, employ a slew of data analysts and data tools, but every team is reluctant to share how data is used, and where they derive insights. According to the 2014 SABR Analytics Conference, the new frontier of baseball data is not just about scouting players, but keeping players healthy and injury-free. The new area of research, just in in its infancy, is marrying baseball statistics with medical injury research.

Medical analysts are the new data darlings of baseball operations.

Chris Marinak, Sr. Vice President of Major League Baseball, implemented MLB’s switch to electronic medical records, and believes medical injury research will provide new insights over the next five or ten years,

I actually joined MLB in 2008, and I was shocked to see that we didn’t have a system for tracking injuries or medical information at a de-identified level. We were literally keeping a lot of paper documents and putting them into a filing cabinet. It was time for us to get into the 21st century.

So starting in the 2010 season, we rolled out an electronic medical records system working with the players’ association that allows our medical staff to enter in medical information on every single player injury and the treatments that those players get. And then that information is all stored in one place, so that when you go from one team to the next, it flows along with you.

Marinak says the ancillary benefit is that MLB now has an injury tracking system where they can track trends in the industry.

  • What are the most common injuries?
  • How many collisions at home plate?
  • How many concussions?
  • How many UCL surgeries?

This data is analyzed at a de-identified level to find the drivers of lost time, and the injuries keeping players off the field. “So we can hopefully keep them healthier,” according to Marinak.

Baseball is a Data Driven Industry

Baseball is a sport that has always been hungry for statistics. Sabermetrics, the study of baseball’s in-game play, has been around since the middle of the 20th century. But in 2002 and 2003, Sabermetrics became “Moneyball” as the Oakland As advanced to the playoffs with their analytic approach to assembling a competitive team, despite a lack of competitive dollars.

Video, Biomechanics, and Data

Matisse VerDuyn Fastest Bat Speed 101 MPH

CLICK TO PLAY VIDEO ANALYSIS OF BAT SPEED

With the advent of new technologies, PITCHf/x data and Sportsvision video in 2006, the world of baseball was set to explode with big data and predictive analytics. Detailed data became accessible for every hit and pitch in a game.

Batting and pitching biomechanics also started to be video analyzed at the high school level. In 2009, my son clocked an official bat speed of 101 miles per hour, one of the fastest recorded bat speeds in the country for any amateur or professional player.

Bat speed is recorded via a static ball test, hitting off of a tee; exit speed is recorded hitting a pitched ball.

An injury sidelined his play, so he started experimenting with this new PITCHf/x data. His early web-based program would let you compare MLB pitchers and batters, and team matchups. Having baseball experience would help him provide insights for an individual player’s performance enhanced by data visualizations like heat maps.

Although PITCHf/x stated its data could not be used for commercial purposes, it didn’t take long for the financial world to play ball – Bloomburg Sports was born in 2011. The company’s latest technology (recently sold) has the capability to create every imaginable data point from video captured from play performance, whether that video is captured live or from a stream.

Do you want to know how many times a player licks his lips before fielding a ball? – Dan Cohen, Bloomberg Sports

Tracking Body Movements

Dr. Glenn Fleisig of the American Sports Medicine Institute says they look at what a person’s body is doing and that’s what biomechanics is, “Tracking where the ball went is all good, but we look at how did their body get there. The new thing teams are embracing is biomechanics.” More information will come from wearable tech and self-tracking technologies.

MLB is doing a lot more tracking of player movements utilizing Trackman and through studies at MIT. Marinak says having more of that information publicly available will be important to innovation, but right now it’s just too big, “A game’s worth of data in Trackman is 7 terabytes. So we’re talking about big data at a massive scale.” He cautions that how this data is treated will be different because it is medical information, and keeping a player’s medical information needs to be private.

Dr. Stan Conte (formerly with the SF Giants and now with the Los Angeles Dodgers) is a leading expert in medical injury research in baseball. He says they focus on “changes” in the data. He explains medical data is dirty data, so it is very difficult to analyze.

The data is getting better, and with more data, we’ll be able to go into areas that we hadn’t thought about before. – Dr. Stan Conte

296Baseball28They Might Be (Tech) Giants

The SF Giants already have a reputation as the tech giants in baseball. Where else would you expect to see players taking batting practice with Google Glass?

But now that PITCHf/x also tracks every defensive play, it has been reported that the San Francisco Giants do defensive shifts better than all MLB teams. Is the team’s proximity to Silicon Valley, and its innovative CIO Bill Schlough, its World Series advantage? Or is it their overall focus on innovation?

The only team with “innovation” built into their mission statement.

The San Francisco Giants are dedicated to enriching our community through innovation and excellence on and off the field.

In 2004, the SF Giants were the first to offer Wi-Fi throughout their stadium. Today, approximately 35% of fans are online at games. The stadium’s “fat pipe” allows fans to easily upload content via the Giants app or social channels like Faceboook, Twitter, and Instagram.

In 2009, SF Giants CIO Bill Schlough introduced dynamic ticket pricing (DTP), allowing the price of game tickets to go up or down depending on popularity and availability. Other teams now use DTP, and the idea has spread to restaurants, movie theaters, and the performing arts.

Healthy Eating: Let Them Eat Kale

This year, the SF Giants opened a 4,320 sq. ft. edible garden and restaurant, affectionately called the “kale garden”, that sits overlooking center field. In addition to providing healthy fare for fans and players, the innovative garden will be used as an open-air classroom for students during the Giants’ off-season, where Bay Area youth will go to learn about sustainability, urban farming and healthy eating.

Gaining respect early as a technology leader was key for Schlough’s career, as the Giants let him run his own department with the ease and precision he wanted to do it in. It’s tremendous the impact Schlough has had on the Giants, but eventually that impact will affect the MLB as a whole.  – Justin Kasser

Now, let’s play ball!

Categories: News and Views , All

October 21,2014

9:05

First, do no harm.

Four simple words that are synonymous with healthcare. It’s a principle that everyone in the industry – not just physicians – should adhere to.

So shame on us all for our part in allowing an EHR vendor to shut off a practice’s access to their patients’ medical records and for recklessly putting patients at risk.

Background: Full Circle Health Care in Maine purchased an EHR from HealthPort in 2010. Originally the maintenance fees were $300 a month. A few months later CompuGroup Medical purchased HealthPort and increased the maintenance fees to $2,000 a month. The practice protested the price increase and claimed CompuGroup failed to deliver hardware upgrades that had been paid for. The parties spent several months arguing and for 10 months the practice did not pay its maintenance bills. Finally in July, CompuGroup shut off the practice’s access to its medical records.

The details as to why the fees jumped so much and whether CompuGroup had the legal right to do so are a little unclear. What is clear is that multiple parties are at fault for allowing such a mess to occur.

Let’s start with the government, which created the HITECH program and promised thousands of dollars for providers willing to adopt and meaningfully use EHRs. Though the objectives were admirable, CMS failed to adequately address all the “what if” scenarios in its rush to move the program forward. The legislation and final rule provide no guidelines for protecting patient records in the event of a vendor/provider disagreement, financial hardship, or business discontinuance. Undoubtedly we’ll see plenty more disputes like this one in the coming years.

Tdo no harmhe practice also gets a share of the blame. The owner should have invested in legal advice before signing a $72,000 contract for something as critical as an EHR system. Did she skip this step in her haste to achieve Meaningful Use and earn incentive payments? Furthermore, even if she disputed the increase in maintenance pricing, shouldn’t she, at a minimum, have continued paying the $400 a month fee she believed was the correct amount? Perhaps the vendor would have been more willing to come to an acceptable agreement if she hadn’t stopped paying altogether.

CompuGroup, of course, looks like the really bad guy here. The multi-national company has annual revenues of about $600 million. Did they really need to pull the plug on this practice over a piddling $40,000? The company’s general counsel says the situation is similar to an electric company shutting off power when a customer fails to pay. Perhaps, but many municipalities and some states have laws that prohibit the discontinuance of services under certain conditions, such as in extreme cold weather or when a child or sick person is in residence. In other words, there are laws to protect consumers against potentially harmful actions. (See: EHRs And The Law: When Interoperability Isn’t a Choice)

Which brings us to the seemingly forgotten patient, who arguably is – or should be – the owner of his or her own record. We do have federal and state laws that give patients the right to access and inspect their medical records. Perhaps the practice’s 4,000 patients should all send CompuGroup a written request for a copy of their records. Maybe an attorney who is smarter than me should look into that.

Until the mess is settled, we have a practice seeing patients without the benefit of medication and allergy lists, details on previous treatments, or lab and test results. And everyone involved is hoping that no patients are harmed.

Whether our role in healthcare is policy maker, technology developer, provider, or HIT geek, we really need to do better.

Categories: News and Views , All

October 16,2014

6:00

Cuisinart DesignIndustrial designer Marc Harrison suffered a brain injury while sledding when he was 11-years old. The injury and years of rehabilitation would provide Harrison with insight and inspiration for his future work in industrial design.

Harrison would go on to develop the philosophy of Universal Design – the idea that products should be developed for people of all abilities, not just for people of average size, shape, and ability.

Harrison’s study of people with disabilities led to the iconic design of the Cuisinart food processor, a design still relevant today after more than 40 years. The simple, clean design would also come to be a major influence for Steve Jobs in the development of the Macintosh computer.

If you put the original Mac in 1984 side-by-side with an early ’80s Cuisinart, the influence on the physical design of the Mac is immediately obvious. Not only is the Mac designed with software for accessibility and more universal design, but its physical design had this perhaps unknown influence as well. – Dean Karavite

Designing for the “extreme user” vs. the average user results in more innovative designs.

A Podcast for Everyone

Click Image to play the podcast

I learned about Harrison from an exceptional interview with Dean Karavite, a Human Interaction Specialist in Clinical Informatics at Children’s Hospital of Philadelphia. Dean was interviewed by Whitney Quesenbery, co-author of the book, “A Web for Everyone”.

The podcast available on iTunes covers Dean’s work on “Accessible Designs for PHRs”. He discusses healthcare interoperability in layman’s terms, and provides answers to some valuable questions:

The Accessible Designs project seeks to unite accessibility and usability to inform the future development of health IT that will be effective for all users.

POWER USERS

It is important to point out that people with disabilities are not all people in poor health.

People with disabilities use the health care system a lot and in many different ways. –Whitney Quesenbery

Among study participants with various levels of disability, Dean found that people with the highest level of needs – those also with many chronic conditions – were the source of “the most detailed, sophisticated, and innovative ideas on what an accessible PHR should do.”

JUST ASK

Understanding what users want and the problem the application will solve should be the first step in any development process. How does user-centered design firm IDEO find people to interview for needfinding? While it is great to speak with average users, the most interesting interviews come from “extreme users.” This idea of extreme users is also explored in “Just Ask: Integrating Accessibility throughout Design” by Shawn Henry.

As part of our project exploring accessible Personal Health Records, one of the methods we have applied was performing a survey with 150 people with different disabilities. In that survey, we had our participants rate over 20 health topics in two ways.

First, in terms of how important the particular topic was to their health and healthcare, and second, their current level of satisfaction with a particular issue or topic.

The number one, most highly rated issue in terms of importance was the ability to share medical information between different providers’ offices, and hospitals.

The real underlying issue here isn’t just the transfer of data, but care coordination, which is the collaboration, not just communication, but collaboration between multiple healthcare providers. – Dean Karavite interview with Whitney Quesenbery

Assessment of Three PHR Systems

Another part of the “Accessibility Designs” project looked to assess the current state of PHR systems for accessibility, functionality and usability.

Unfortunately, vendors were reluctant to participate.

These results came from systems project team members used to manage their own health including a hospital PHR, an ambulatory PHR, and a consumer PHR.

PHR Assessment

According to the project,  “The hospital PHR was the least functional and least usable, yet was the most accessible. Meanwhile the ambulatory PHR was the most functional and most usable, yet failed to meet basic accessibility standards. The consumer PHR was quite usable despite failing to meet accessibility criteria, and failed one crucial accessibility requirement: the entry of dates by people with visual and/or physical disabilities, a critical action required by almost every task managed by the system.”

Now We All Have It, and We Absolutely Love It

Many of the technologies used today are the result of work used to meet the needs of people with disabilities:

“For example, touch screens, on-screen keyboards with word prediction, zoomable displays, speech recognition, text-to-speech. Think about it. It took about 10 to 15 years, and now we all have it on our computers, our phones and other devices, and we absolutely love it.” – Dean Karavite

Dr. David Do, MD says, “The healthcare industry has much to learn around the design and usability concerns espoused by Silicon Valley.” Whitney Quesenbery suggests,

Get out of your little box and look for inspiration all over the place.

Good ideas can come from anywhere!

Categories: News and Views , All

January 6,2014

16:11
GNUmed now supports the following workflow:

- patient calls in asking for documentation on his back pain

- staff activates patient

- staff adds from the document archive to the patient
  export area a few documents clearly related to episodes
  of back pain

- staff writes inbox message to provider assigned to patient

- provider logs in, activates patient from inbox message

- provider adds a few more documents into the export area

- provider screenshots part of the EMR into the export area

- provider includes a few files from disk into export area

- provider creates a letter from a template and
  stores the PDF in the export area

- provider notifies staff via inbox that documents
  are ready for mailing to patient

- staff activates patient from inbox message

- staff burns export area onto CD or DVD and
  mails to patient

- staff clears export area

Burning media requires both a mastering application
(like k3b) and an appropriate script gm-burn_doc
(like the attached) to be installed. Burning onto
some media the directory passed to the burn script
produces an ISO image like the attached.

Karsten
--
GPG key ID E4071346 @ gpg-keyserver.de
E167 67FD A291 2BEA 73BD  4537 78B9 A9F9 E407 1346

November 26,2013

5:10
Here it is

0.) do a full backup. Save it on some other media then your harddisk ! Do it,
now.

1.) Install PG 9.3 ( I tried with 32bit but should not matter).
- http://get.enterprisedb.com/postgresql/postgresql-9.3.1-1-windows.exe

2.) Run the installer and select (English_UnitedStates) for locale (others
might work as well). Make sure it installs itself on port 5433 (or other but
never ! 5432).

3.) Make sure both PG 8.4 and PG 9.3 are running (e.g. via pgadmin3 from PG
9.3)

4.) open a command shell (dos box) - "run as" administrator (!) in Win7

5.) type : RUNAS /USER:postgres "CMD.EXE"
- this will open another black box (command shell) for user postgres
- for the password use 'postgrespassword' (default)

6.) type: SET PATH=%PATH%;C:\Programme\PostgreSQL\9.3\bin;
- instead of Programme it might be Program Files on your computer

7.) type: cd c:\windows\temp
- changes directory to a writable temporary directory

8.) type: pg_dump -p 5432 -Fc -f gnumedv18.backup gnumed_v18

9.) type: pg_dumpall -p 5432 --globals-only > globals.sql

Important : Protect your PG 8.4 by shutting it down temporarly

10.) type in the first command shell : net stop postgresql-8.4
- check that is says : successfully stopped

11.) psql -p 5433 -f globals.sql
- this will restore roles in the new database (PG 9.3 on port 5433)

12.) pg_restore -p 5433 --dbname postgres --create gnumedv18.backup
- this will restore the database v18 into the PG 9.3 on port 5433

Congratulations. You are done. Now to check some things.

########################################
Here you could run the fingerprint script on both databases to check for an
identical hash

https://gitorious.org/gnumed/gnumed/source/f4c52e7b2b874a65def2ee1b37d8ee3fb3566ceb:gnumed/gnumed/server/gm-fingerprint_db.py

########################################

13.) Open gnumed.conf in c:\programme\gnumed-client\
For the profile GNUmed database on this machine ("TCP/IP": Windows/Linux/Mac)]
change port=5432 to 5433.

14. Run the GNUmed client and check that it is working. If it works (no wrong
schema hash detected) you should see all your patient and data.

15. If you have managed to see you patients and everything is there close
GNUmed client 1.3.x.

16.) in the first command shell type: net stop postgresql-9.3

17.) Go to c:\Ptogramme\PostgresPlus\8.4SS\data and open postgresql.conf. Find
port = 5432 and change it to port = 5433

18.) Go to c:\Programme\Postgresql\9.3\data and open postgresql. Find port =
5433 and change it to 5432. This effectively switches ports for PG 8.4 and 9.3
so PG 9.3 runs on the default port 5432.

19.)  Open gnumed.conf in c:\programme\gnumed-client\
For the profile GNUmed database on this machine ("TCP/IP": Windows/Linux/Mac)]
change port=5433 to 5432.

20.) Restart PG 9.3 with: net start postgresql-9.3.

21.) Open the GNUmed client and connect (to PG 9.3 on port 5432).

22.) Leave PG 8.4 in a shutdown state.

So far we have transferred database v18 from PG 8.4 to 9.3. No data from PG
8.4 is touched/lost.

23.) Now you are free to install gnumed-server v19 and gnumed -client 1.4.
Having installed gnumed-server v19 select 'database upgrade' (not boostrap
database) and it will upgrade your v18 database to a v19 database.

In case you experience problems you can always shut down PG 9.3, switch ports again, install client 1.3.x, start PG 8.4 (net start postgresql-8.4) and work with your old setup.

November 13,2013

7:26
The release notes prominently tell us that GNUmed 1.4.x requires at least PostgreSQL 9.1.

If you are running the Windows packages and have let GNUmed install PostgreSQL for you you are good to go since it comes with PostgreSQL 9.2 already.

If you are on Ubuntu or Debian Chances are your system still has PostgreSQL 8.x installed.

First check if you run any software that requires you to continue using PostgreSQL 8.x. If so you can install PG 9.1 side by side with it. If not let PG 9.1 replace PG 8.x

It usually works like this.

sudo apt-get install postgresql-9.1
sudo pg_upgradecluster 8.4 main

Then if you don't need PG 8.4 anymore you could

sudo pg_dropcluster --stop 8.4 main
sudo apt-get purge postgresql-8.4

Have fun.

March 6,2013

11:53

Healthcare executives are continuously evaluating the subject of RFID and RTLS in general.  Whether it is to maintain the hospitals competitive advantage, accomplish a differentiation in the market, improve compliance with requirements of (AORN, JCAHO, CDC) or improve asset utilization and operating efficiency.  As part of the evaluations there is that constant concern around a tangible and measurable ROI for these solutions that can come at a significant price.

When considering the areas that RTLS can affect within the hospital facilities as well as other patient care units, there are at least four significant points to highlight:

Disease surveillance: With hospitals dealing with different challenges around disease management and how to handle it.  RTLS technology can determine each and every staff member who could have potentially been in contact with a patient classified as highly contagious or with a specific condition.

Hand hygiene compliance: Many health systems are reporting hand hygiene compliance as part of safety and quality initiatives. Some use “look-out” staff to walk the halls and record all hand hygiene actives. However, with the introduction of RTLS hand hygiene protocol and compliance when clinical staff enter or use the dispensers can now be dynamically tracked and reported on. Currently several of the systems that are available today are also providing active alters to the clinicians whenever they enter a patient’s room and haven’t complied with the hand hygiene guidelines.

Locating equipment for maintenance and cleaning:

Having the ability to identify the location of equipment that is due for routine maintenance or cleaning is critical to ensuring the safety of patients. RTLS is capable of providing alerts on equipment to staff.

A recent case of a hospital spent two months on a benchmarking analysis and found that it took on average 22 minutes to find an infusion pump. After the implementation of RTLS, it took an average of two minutes to find a pump. This cuts down on lag time in care and can help ensure that clinicians can have the tools and equipment they need, when the patient needs it.

There are also other technologies and products which have been introduced and integrated into some of the current RTLS systems available.

EHR integration:

There are several RTLS systems that are integrated with Bed management systems as well as EHR products that are able to deliver patient order status, alerts within the application can also be given.  This has enabled nurses to take advantage of being in one screen and seeing a summary of updated patient related information.

Unified Communication systems:

Nurse calling systems have enabled nurses to communicate anywhere the device is implemented within the hospital facility, and to do so efficiently. These functionalities are starting to infiltrate the RTLS market and for some of the Unified Communication firms, it means that their structures can now provide a backbone for system integrators to simply integrate their functionality within their products.

In many of the recent implementations of RTLS products, hospital executives opted to deploy the solutions within one specific area to pilot the solutions.  Many of these smaller implementations succeed and allow the decision makers to evaluate and measure the impacts these solutions can have on their environment.  There are several steps that need to be taken into consideration when implementing asset tracking systems:

•             Define the overall goals and driving forces behind the initiative

•             Develop challenges and opportunities the RTLS solution will be able to provide

•             Identify the operational area that would yield to the highest impact with RTLS

•             Identify infrastructure requirements and technology of choice (WiFi based, RFID based, UC integration, interface capability requirements)

•             Define overall organizational risks associated with these solutions

•             Identify compliance requirements around standards of use

Conclusion

RFID is one facet of sensory data that is being considered by many health executives.  It is providing strong ROI for many of the adapters applying it to improve care and increase efficiency of equipment usage, as well as equipment maintenance and workflow improvement. While there are several different hardware options to choose from, and technologies ranging from Wi-Fi to IR/RF, this technology has been showing real value and savings that health care IT and supply chain executives alike can’t ignore.

February 21,2013

14:41

It was not long after mankind invented the wheel, carts came around. Throughout history people have been mounting wheels on boxes, now we have everything from golf carts, shopping carts, hand carts and my personal favorite, hotdog carts. So you might ask yourself, “What is so smart about a medical cart?”

Today’s medical carts have evolved to be more than just a storage box with wheels. Rubbermaid Medical Solutions, one of the largest manufacturers of medical carts, have created a cart that is specially designed to house computers, telemedicine, medical supply goods and to also offer medication dispensing. Currently the computers on the medical carts are used to provide access to CPOE, eMAR, and EHR applications.

With the technology trend of mobility quickly on the rise in healthcare, organizations might question the future viability of medical carts. However a recent HIMSS study showed that cart use, at the point of care, was on the rise from 26 percent in 2008 to 45 percent in 2011. The need for medical carts will continue to grow; as a result, cart manufacturers are looking for innovative ways to separate themselves from their competition. Medical carts are evolving from healthcare products to healthcare solutions. Instead of selling medical carts with web cameras, carts manufacturers are developing complete telemedicine solutions that offer remote appointments throughout the country, allowing specialist to broaden their availability with patients in need. Carts are even interfaced with eMAR systems that are able to increase patient safety; the evolution of the cart is rapidly changing the daily functions of the medical field.

Some of the capabilities for medical carts of the future will be to automatically detect their location within a healthcare facility. For example if a cart is improperly stored in a hallway for an extended period of time staff could be notified to relocate it in order to comply to the Joint Commission’s requirements. Real-time location information for the carts could allow them to automatically process tedious tasks commonly performed by healthcare staff. When a cart is rolled into a patient room it could automatically open the patient’s electronic chart or give a patient visit summary through signals exchanged between then entering cart and the logging device kept in the room and effectively updated.

Autonomous robots are now starting to be used in larger hospitals such as the TUG developed by Aethon. These robots increase efficiency and optimize staff time by allowing staff to focus on more mission critical items. Medical carts in the near future will become smart robotic devices able to automatically relocate themselves to where they are needed. This could be used for scheduled telemedicine visits, the next patient in the rounding queue or for automated medication dispensing to patients.

Innovation will continue in medical carts as the need for mobile workspaces increase. What was once considered a computer in a stick could be the groundwork for care automation in the future.

September 10,2012

9:35

This has been an eventful year for speech recognition companies. We are seeing an increased development of intelligence systems that can interact via voice. Siri was simply a re-introduction of digital assistants into the consumer market and since then, other mobile platforms have implemented similar capabilities.

In hospitals and physician’s practices the use of voice recognition products tend to be around the traditional speech-to-text dictation for SOAP (subjective, objective, assessment, plan) notes, and some basic voice commands to interact with EHR systems.  While there are several new initiatives that will involve speech recognition, natural language understanding and decision support tools are becoming the focus of many technology firms. These changes will begin a new era for speech engine companies in the health care market.

While there is clearly tremendous value in using voice solutions to assist during the capture of medical information, there are several other uses that health care organizations can benefit from. Consider a recent product by Nuance called “NINA”, short for Nuance Interactive Natural Assistant. This product consists of speech recognition technologies that are combined with voice biometrics and natural language processing (NLP) that helps the system understand the intent of its users and deliver what is being asked of them.

This app can provide a new way to access health care services without the complexity that comes with cumbersome phone trees, and website mazes. From a patient’s perspective, the use of these virtual assistants means improved patient satisfaction, as well as quick and easy access to important information.

Two areas we can see immediate value in are:

Customer service: Simpler is always better, and with NINA powered Apps, or Siri like products, patients can easily find what they are looking for.  Whether a patient is calling a payer to see if a procedure is covered under their plan, or contacting the hospital to inquire for information about the closest pediatric urgent care. These tools will provide a quick way to get access to the right information without having to navigate complex menus.

Accounting and PHR interaction: To truly see the potential of success for these solutions, we can consider some of the currently used cases that NUANCE has been exhibiting. In looking at it from a health care perspective, patients would have the ability to simply ask to schedule a visit without having to call. A patient also has the ability to call to refill their medication.

Nuance did address some of the security concerns by providing tools such as VocalPassword that will tackle authentication. This would help verify the identity of patients who are requesting services and giving commands. As more intelligence voice-driven systems mature, the areas to focus on will be operational costs, customer satisfaction, and data capture.

February 5,2013

18:01

[...] medical practice billing software  encourage [...]

October 20,2014

16:57

I’ve been interested in the new “wearables” segment for a while. I reached out to Cameron Graham, the managing editor at TechnologyAdvice where he oversees market research for emerging technology, to give us some evidence-driven advice about wearables that entrepreneurs, innovators, healthcare providers, and payers can use for decision making. Specifically, what does the current research show and what are the actionable insights for how to incentivize patients to use them and figure out why patients might pay for them? Cameron thinks that wearable health technology could help improve patient outcome monitoring, if insurance companies and providers work together. He elaborated:

Wearable health technology (or mHealth as some call it) is one of the emerging frontiers in medicine. Fitness tracking devices could allow the healthcare industry to better measure patient outcomes, monitor patient populations for emerging trends, and give preventative healthcare advice based on quantitative measurements (such as daily step counts or heart-rate). We surveyed 979 US adults about their fitness tracking habits, in order to determine current the usage rate for this technology. We then further surveyed 419 of those adults, who identified as non-trackers, about what incentives would convince them to use wearable health monitors. Here are some of our takeaways for vendors and providers:

1. The wearable health market remains small, but is growing steadily

In order to gauge how many adults are currently generating personal health data that would be useful in either patient treatment or preventative medicine, we asked a random, nationwide sample of adults whether they currently tracked their weight, diet, or exercise using a fitness tracking device or smartphone app.

74.9 percent of respondents indicated they did not track any of those variables using either a fitness tracker or smartphone app. 25.1 percent reported tracking such stats.

Out of the roughly one quarter of adults who do track their fitness, 14.1 percent said they used a smartphone app, and 11 percent said they used a fitness tracker. There is currently little data on such demographics, although the Pew Internet Research Project conducted a survey in 2012 looking at similar trends. In their report, they noted that seven percent of adults tracked health indicators using an app. Combining these results, we can see that the market for health tracking applications has approximately doubled over the last two years.

As more consumers adopt such technology, and rely on it for monitoring their health, providers need to become involved in the discussion. There is limited data that can be draw from a sample of just 25 percent of a patient population. If providers can encourage adoption among a majority of their patients however, they will gain greater insight into current health habits, and be able to provide more tailored advice.

2. Physicians can play a large role in encouraging tracking but there are are few incentives in place for them to do so

Looking into what incentives could convince non-tracking adults to use such devices, we found great potential for healthcare providers to encourage tracking habits among their patients. It appears patients want their physicians involved more in monitoring but our healthcare system doesn’t have the right incentives or payment structures available to compensate providers.

48.2 percent of adults said they would use a wearable fitness tracker if their physician provided one. While this may be financially unrealistic for smaller practices, wearable activity trackers (like the FitBit or Jawbone UP) will likely become cheaper as more sophisticated, multi-purpose devices enter the market, such as the forthcoming Apple Watch.

If physicians were able to get half of the three-quarters of non-tracking adults to start measuring their fitness with wearable devices, it would create huge amounts of patient-generated data for the healthcare industry to analyze.

The infrastructure for handling this data is largely in place. The most popular electronic health record provider, Epic Systems, recently announced a partnership with Apple that will allow hospitals to easily integrate wearable data through Apple’s HealthKit platform into patient portals and records.

Promoting the use of such devices should now be a goal for physicians looking to gain greater insight into their patient population. The question would be why Physicians would do this without additional compensation either directly from their patients or indirectly through insurers.

3. Insurance companies and providers need to form partnerships

While a significant portion of adults would use physician-provided devices, health insurance companies may be the ultimate key to promoting widespread fitness tracker adoption.

A total of 57.1 percent of respondents said they would be more likely (or much more likely) to wear a fitness a tracker if they could receive lower health insurance premiums. In fact, this was a more compelling incentive than the possibility of receiving better healthcare advice from their physician (just 44.3 percent of respondents said that would make them more likely to use a tracker).

By agreeing to use a fitness tracker, insurance customers would become eligible for special discounts, perhaps for walking a set number of steps each day, or raising their heartbeat for a certain period of time. Discounts could be given out directly or through an employer.

Some companies are already experimenting with such systems. Humana insurance has a new Vitality program that allows employees to opt-in to fitness tracking in exchange for possible discounts. Car insurance companies have also found success by offering lower rates for safe-driving, as measured through in-car tracking devices.

If providers want to encourage fitness and health tracking among their patients, they should evaluate the possibility of providing devices to their patients, either for free or at a reduced cost. At the very least, they should make patients aware of the benefits of such devices, and encourage them to automatically share such data through their patient portal.

Long term, providers will likely need to collaborate with insurance companies in order to establish a data sharing system for such information, which can allow for physicians to better monitor their patient population, and provide more accurate, tailored diagnoses. A universal patient record system would be ideal, although given current interoperability standards, an insurance-provider arrangement is more likely.

October 13,2014

20:38

MedCityNews invited me to attend their ENGAGE “Innovation in Patient Engagement” Conference and I found the content, speakers, and overall quality quite good. Since I chair several conferences every year I know how hard it is to pull off a good one so I’d like to congratulate MedCityNews for pulling off a great event. I asked HITSphere‘s Vik Subbu, our Digital Health editor that focuses on Bio IT and Pharma IT, to summarize what we learned at the event. Here’s Vik’s recap of the conference:

The goal of the ENGAGE was to highlight the importance of patient awareness and engagement in developing and managing novel digital health innovations. The conference was attended by industry experts from various disciplines ranging from academic hospitals, non-profit organizations, digital health start-ups, venture capital, service providers and pharmaceutical companies. The interactions between product developers and patients proved to be worthwhile as it is often rare to get both ends of the spectrum together. The point of the conference, driven home in almost every session, was that having patient (i.e. customer) input early on shapes better product development decisions and viewpoints.

Top Nine Insights for digital health innovators and providers:

  1. Engage patients upfront prior to developing ANY digital health solution. This seems obvious but it’s not always done well — we just assume patients have various needs without testing our hypotheses.
  2. Healthcare providers need to look at existing information for patient care – let’s use what we already have to improve care. This means innovators should not be creating new data collection or data entry screens if that same information can be integrated from an existing solution (such as an EHR, lab system, etc.)
  3. Stay away from the “hype” – providers do not have the time to test out digital health solutions/applications. Do your homework with patients, payers and providers before embarking on developing a digital health solution. It’s easy to create software, it’s very hard to find clinicians willing to spend time testing your software-based hypotheses.
  4. Clinical work flows will change in the future – consider these changes and integrate your digital health solution into these work flows. This means you should abstract your workflows, protocols, procedures, etc. from the core software into distributed workflow or BPM style systems. Whatever you assume the workflow to be, it’s likely to be wrong as it gets into complex environments like hospitals and health systems. Do yourself a favor and abstract it so that you can flex the software as move from enterprise to another.
  5. Do not compete with physicians – digital health applications should support not supplant physicians. If you’re creating educational systems for patients give them data that they can share with their physicians. If you’re creating diagnostic systems, create them so that the data they generate can easily be shared with clinicians and existing systems.
  6. Enhance the patient experience in the clinical setting through digital health. This can be done in many ways, starting simply as digital signage — going to patient navigators and even as far as digital avatars. Don’t think about the current experience and try to slightly improve it; instead, think of completely new ways of solving old problems.
  7. Consider “slow” technology – design the digital health as you go along while incorporating patient input and reflections and find the right solution, not focus on the technology – the best technology fades into the background. Create solutions with Clayton Christian’s JTBD model in mind — what problem are you really solving?
  8. The common saying that “everyone is a patient” is untrue. There is a clear line between REAL patients with chronic illnesses that have to deal with the day-to-day challenges with our healthcare system vs. someone with a cold/cough
  9. Do not underestimate the importance of patient family groups and caregivers — sometimes your solution for patients might best be targeted at caregivers and not the patients.

Did you attend ENGAGE? What did you learn? Please share your thoughts below.

October 10,2014

15:26

It’s getting easier and easier to build unregulated software these days but it’s still pretty hard to create regulated/certified systems such as EHRs, medical device software, and government IT. To help create better systems we all know we need better user requirements; however, “heavyweight requirements” efforts have been shunned, especially in unregulated systems, over the past decade in favor of “user stories” and more agile specifications. But, are agile user stories the best way to go in regulated systems where requirements traceability and safety analysis is a must?  I invited Abder-Rahman Ali, currently pursuing his Medical Image Analysis Ph.D. in France, to come back and give us advice on whether there’s room for both user stories and SRSs in regulated industries or if we’re stuck with formal requirements specs. The following is Abder-Rahman’s third installment for this blog and I’m excited he’ll be tackling such an important topic. As always, he can be reached via e-mail or twitter.  Here’s what Abder-Rahman says about User Stories vs. Software Requirements Specifications:

It was on February, 2001, when seventeen practitioners formed what was called The Agile Manifesto. It seems that since then, we started to hear of the term User Story, although, as will be shown below, it seems that the term appeared before that date.

The questions that may pop-up on someone’s head are, is the User Story just a fancy name to the user requirement? Or, it is actually a new mindset of thinking in the way of dealing with user requirements?

Referring to Wikipedia about the history of user stories, I found that user stories originated with Extreme Programming (XP), but, it wasn’t until 2001, when Ron Jeffries proposed the Three C’s formula: Card, Conversion, Confirmation, where the components of the user stories were captured.

But, what are User Stories after all?

I really liked how Mike Cohn described User Stories, when he said:

User Stories are short, simple description of a feature told from the perspective of the person who desires the new capability, usually a user or customer of the system. They typically follow a simple template:

As a <type of user>, I want <some goal> so that <some reason>.

User Stories are often written on index cards or sticky notes, stored in a shoe box, and arranged on walls or tables to facilitate planning and discussion. As such, they strongly shift the focus from writing about features to discussing them. In fact, these discussions are more important than whatever text is written.

Before moving ahead, and comparing User Stories with Software Requirements Specifications (SRS), let us see how SRS is defined. Based on Chambers, SRS describes the essential behavior of a software product from a user’s point of view, where the purpose of SRS is to be a basis for agreement between the customers and the suppliers on what the software product is to do; a basis for developing the software design; a basis for estimating costs and schedules; a baseline for validation and verification; reducing the development effort; facilitating transfer; and serves as a basis for enhancement.

After knowing what they mean, how can we compare User Stories with SRS? I saw that rather than bringing theory to this part, why not monitor some discussions related to this issue? I thus went through some discussions at a Programmers Stack Exchange thread, and came up with the following:

One of the people involved in the discussion mentioned: To be honest, after spending close to two years immersed in Agile development, I still think “User Story” is just a fancy term for “functional requirement”. That person continues: What User Stories almost never capture, in my experience, are non-functional requirements like performance and security. These kinds of requirements are very difficult to write properly and the format of the User Story simply isn’t very good for capturing them, because they’re more about general product quality and mitigating (but not eliminating) risks rather than meeting a specific user’s need. So, I really think of User Stories as a subset of requirements, with a specific formula, and still use the terms pretty much interchangeably. The one major advantage User Stories do have over requirements is that the word “requirement” suggests that a feature is required where it is often just desired. User Stories can in theory be prioritized and slotted in for any release, whereas requirements appear to be a prerequisite for every release.

Other opinions arise mentioning that SRS focuses on “how” the user interacts with the system, and “how” to implement the functionality. On the other hand, User Stories focus on “what” (interaction between user and system) purpose do features have, such that, the task of a User Story would be a functional requirement, and is the expected work product after the functional tasks have all been completed. Thus, they are completely different things.

Requirements assume that the design of the application is done beforehand, and development is considering the implementation of that design.

User Stories insist that the design of the product is done at the last minute, and is a collaboration between a product person and a developer person, and the details are decided during implementation.

So, as can be noticed, the amount of details provided is different using the two approaches, such that, in the User Story for instance, there is a lot of information that is available not available in the requirement, namely, what is we are trying to achieve with the feature.

Others go and mention that a functional requirement is a formal specification that allows one to know exactly if the software works or not. Whilst a User Story is an informal way to describe a need of one of the User Stories, such that, it doesn’t specify a rigid specification to determine if the software is valid or invalid. Although you can test some part of the User Story, its real completion is when the user says : “Yes, this solves my problem”.

We thus realize that the User Story is a huge paradigm shift in the way to approach the work to be done. A contract here is not made, rather, you are trying to help your user to solve a problem. If you don’t see your user stories as discussion tools with a real user, then you are actually not using User Stories.

This post can grow bigger and bigger, and seems that when people attempt describe the notions “User Story” and “user requirement”, such descriptions come from their experience, and how they use each of them. Going through the comparisons above may not reveal clearly the differences between both terms. For that, we chose to interview Agile experts about this issue, for which answers will be shown in the next post.

Stay tuned until then, and don’t hesitate to share your views in this topic, and how you approach those two terms.

March 12,2010

11:01
This blog is now located at http://blog.rodspace.co.uk/. You will be automatically redirected in 30 seconds, or you may click here. For feed subscribers, please update your feed subscriptions to http://blog.rodspace.co.uk/feeds/posts/default. Rodhttp://www.blogger.com/profile/12607263970096550308noreply@blogger.com0

March 3,2010

4:07
I've just heard about the Information Technology and Communications in Health (ITCH) which will be held February 24 - 27, 2011, Inn at Laurel Point, Victoria, BC Canada.I'd not heard of this conference before but the current call for papers looks interesting.Health Informatics: International Perspectives is the working theme for the 2011 international conference. Health informatics is now a Rodhttp://www.blogger.com/profile/12607263970096550308noreply@blogger.com0
3:59
The report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England sets out the way forward for the future of the professions which was published yesterday, calls for the establishment of a "high-level group to determine how to build nursing and midwifery capacity to understand and influence the development and use of new technologies. It must consider how pre- and Rodhttp://www.blogger.com/profile/12607263970096550308noreply@blogger.com0

June 9,2013

16:10

“Large collections of electronic patient records have long provided abundant, but under-explored information on the real-world use of medicines. But when used properly these records can provide longitudinal observational data which is perfect for data mining,” Duan said. “Although such records are maintained for patient administration, they could provide a broad range of clinical information for data analysis. A growing interest has been drug safety.”

In this paper, the researchers proposed two novel algorithms—a likelihood ratio model and a Bayesian network model—for adverse drug effect discovery. Although the performance of these two algorithms is comparable to the state-of-the-art algorithm, Bayesian confidence propagation neural network, by combining three works, the researchers say one can get better, more diverse results.

via www.njit.edu

I saw this a few weeks ago, and while I haven't had the time to delve deep into the details of this particular advance, it did at least give me more reason for hope with respect to the big picture of which it is a part.

It brought to mind the controversy over Vioxx starting a dozen or so years ago, documented in a 2004 article in the Cleveland Clinic Journal of Medicine. Vioxx, released in 1999, was a godsend to patients suffering from rheumatoid arthritic pain, but a longitudinal study published in 2000 unexpectedly showed a higher incidence of myocardial infarctions among Vioxx users compared with the former standard-of-care drug, naproxen. Merck, the patent holder, responded that the difference was due to a "protective effect" it attributed to naproxen rather than a causative adverse effect of Vioxx.

One of the sources of empirical evidence that eventually discredited Merck's defense of Vioxx's safety was a pioneering data mining epidemiological study conducted by Graham et al. using the live electronic medical records of 1.4 million Kaiser Permanente of California patients. Their findings were presented first in a poster in 2004 and then in the Lancet in 2005. Two or three other contemporaneous epidemiological studies of smaller non-overlapping populations showed similar results. A rigorous 18-month prospective study of the efficacy of Vioxx's generic form in relieving colon polyps showed an "unanticipated" significant increase in heart attacks among study participants.

Merck's withdrawal of Vioxx was an early victory for Big Data, though it did not win the battle alone. What the controversy did do was demonstrate the power of data mining in live electronic medical records. Graham and his colleagues were able to retrospectively construct what was effectively a clinical trial based on over 2 million patient-years of data. The fact that EMR records are not as rigorously accurate as clinical trial data capture was rendered moot by the huge volume of data analyzed.

Today, the value of Big Data in epidemiology is unquestioned, and the current focus is on developing better analytics and in parallel addressing concerns about patient privacy. The HITECH Act and Obamacare are increasing the rate of electronic biomedical data capture, and improving the utility of such data by requiring the adoption of standardized data structures and controlled vocabularies.

We are witnessing the dawning of an era, and hopefully the start of the transformation of our broken healthcare system into a learning organization.

 

Source: FutureHIT

June 7,2013

13:51

I believe if we reduce the time between intention and action, it causes a major change in what you can do, period. When you actually get it down to two seconds, it’s a different way of thinking, and that’s powerful. And so I believe, and this is what a lot of people believe in academia right now, that these on-body devices are really the next revolution in computing.

via www.technologyreview.com

I am convinced that wearable devices, in particular heads-up devices of which Google Glass is an example, will be playing a major role in medical practice in the not-too-distant future. The above quote from Thad Starner describes the leverage point such devices will exploit: the gap that now exists between deciding to make use of a device and being able to carry out the intended action.

Right now it takes me between 15 and 30 seconds to get my iPhone out and do something useful with it. Even in its current primitive form, Google Glass can do at least some of the most common tasks for which I get out my iPhone in under five seconds, such as taking a snapshot or doing a Web search.

Closing the gap between intention and action will open up potential computing modalities that do not currently exist, entirely novel use case scenarios that are difficult even to envision before a critical mass of early adopter experience is achieved.

The Technology Review interview from which I extracted the quote raises some of the potential issues wearable tech needs to address, but the value proposition driving adoption will soon be truly compelling.

I'm adding some drill-down links below.

Source: FutureHIT
11:22

Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH.

via www.annfammed.org

One bit of good news about the Patient Centered Medical Home (PCMH) model: here is a study showing that in spite of considerable challenges to PCMH implementation, the transformations it embodies can be and are being implemented even in small primary care practices serving disadvantaged populations.

Source: FutureHIT

October 18,2014

11:54
Call for Articles for a Special Section of Semiotica, the Journal of the International Association for Semiotic Studies on the theme of “Social Representations, ICTs and Community Empowerment”.

This special section will provide an overview of the use of Social Representations Theory (SRT) (Moscovici, 1961), for empowering local communities, with a specific focus on the role of Information and Communication Technologies (ICTs), such as the Internet, desktop and mobile devices, radios, etc.

Interested researchers are invited to submit an abstract proposal (word file) of about 500 words via e-mail.

Abstracts should be accompanied by the following information about each of the authors:
  • Name
  • Position
  • Affiliation
  • Contact Information
The deadline for abstracts submission is November 21st, 2014.

Inquiries and submissions can be forwarded electronically to:

Dr. Sara Vannini
Università della Svizzera italiana, (USI Lugano, Switzerland)
sara.vannini AT usi.ch

More information can be found here:
http://www.newmine.org/call-for-articles-social-representations-icts-and-community-empowerment

Thank you so much for your help!

Sara
Sara Vannini, PhD
Visiting Researcher - TASCHA
Executive Director - NewMinE Lab
PostDoctoral Researcher - BeCHANGE Research Group
sara.vannini.usi AT gmail.com
website: http://www.saravannini.com


My source: ciresearchers AT vancouvercommunity.net

Additional link [pj]: Wikipedia - Social representation
Categories: News and Views , All

September 28,2014

17:34
Dear ERCIM News Reader,

ERCIM News No. 99 has just been published at
http://ercim-news.ercim.eu/en99

http://ercim-news.ercim.eu/en99Special Theme: "Software Quality"
http://ercim-news.ercim.eu/en99/special/

And on the occasion of ERCIM’s 25th anniversary, we published a selection of articles on the future challenges of ICST:
http://ercim-news.ercim.eu/en99/challenges-for-icst

Keynote by Willem Jonker, CEO EIT ICT Labs: "The Future of ICT: Blended Life"
http://ercim-news.ercim.eu/en99/keynote/the-future-of-ict-blended-life



This issue is also available for download as:
pdfhttp://ercim-news.ercim.eu/images/stories/EN99/EN99-web.pdf
epub: http://ercim-news.ercim.eu/images/stories/EN99/EN99.epub

Next issue: No. 100, January 2015 - Special Theme: "Scientific Data Sharing"

Thank you for your interest in ERCIM News.
Feel free to forward this message to others who might be interested.

Best regards,
Peter Kunz
ERCIM News central editor

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ERCIM offers fellowships for PhD holders from all over the world.
Next application deadline: 30 September 2014 http://fellowship.ercim.eu/
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is published quarterly by ERCIM, the European Research Consortium for Informatics and Mathematics.
The printed edition will reach about 6000 readers.
This email alert reaches over 7300 subscribers.
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ERCIM - the European Research Consortium for Informatics and Mathematics - aims to foster collaborative work within the European research community and to increase co-operation with European industry. Leading European research institutes are members of ERCIM. ERCIM is the European host of W3C.
http://www.ercim.eu/

Follow us on twitter http://twitter.com/#!/ercim_news
and join the open ERCIM LinkedIn Group http://www.linkedin.com/groups/ERCIM-81390
Categories: News and Views , All

September 9,2014

14:08

Hi Peter

We are delighted to introduce our new series of Health Insights. These free to attend events for healthcare professionals feature interactive round table activities, news on how the latest innovations support the health and care community, and best practice experiences from NHS Trust colleagues.

CLICK HERE TO SEE NEW DATES AND LOCATIONS

Starting in Leeds and Newbury this October and held in association with NHS England, each one day conference will feature:

Digital Discovery Sessions

- facilitated round tables exploring procurement issues

An update from NHS England on Tech Funds and Open Source Programme
Host Roy Lilley, popular Healthcare Broadcaster, with lively panel debates

Speakers will include Rob Webster, CEO of NHS Confederation, Tim Straughan, Director of Health and Innovation at Leeds and Partners, and Clive Kay, Chief Executive of Bradford Teaching Hospitals.

REGISTER FREE TODAY

We hope to see you at your local Health Insights.

Kind regards

Samantha Phillips
HIMSS UK

Categories: News and Views , All

October 14,2012

20:05

Image of clipboard with checklist

 

Twitter, like the Internet in general, has become a vast source of and resource for health care information. As with other tools on the Internet it also has the potential for misinformation to be distributed. In some cases this is done by accident by those with the best intentions. In other cases it is done on purpose such as when companies promote their products or services while using false accounts they created.

In order to help determine the credibility of tweets containing health-related content I suggest the using the following checklist (adapted from Rains & Karmikel, 2009):

  1. Author: Does the tweet contain a first and last name? Can this name be verified as being a real person by searching it on the Internet?
  1. Date: When was the tweet sent? If it is a re-tweet when was the original tweet sent?
  1. Reference: Does the tweet reference a source? Is this source reliable?
  1. Statistics: Does the tweet make claims of effectiveness of a product or service using statistics? Are the statistics used properly?
  1. Personal story or testimonials: Does the tweet contain claims from an individual who has used or conducted research on the product or service? Is this individual credible?
  1. Quotations: Does the tweet quote or cite another source of information (e.g. a link) that can be checked? Is this source credible?

Ultimately it is up to the individual to determine how to use health information they find on Twitter or other Internet sources. For patients anecdotal or experiential information shared by others with the same illness may be considered very credible. Others conducting research may find this a less valuable information source. Conversely a researcher may only be looking for tweets that contain reference to peer-reviewed journal articles whereas patients and their caregivers may have little or no interest in this type of resource.

Reference

Rains, S. A., & Karmike, C. D. (2009). Health information-seeking and perceptions of website credibility: Examining Web-use orientation, message characteristics, and structural features of websites. Computers in Human Behavior, 25(2), 544-553.

 

 

 

 

 

June 26,2012

14:35

The altmetric movement is intended to develop new measures of production and contribution in academia. The following article provides a primer for research scholars on what metrics they should consider collecting when participating in various forms of social media.

Twitter

ThinkUp

If you participate on Twitter you should be keeping track of the number of tweets you send, how many times your tweets are replied to, re-tweeted by other users and how many @mentions (tweets that include your Twitter handle) you obtain. ThinkUp is an open source application that allows you to track these metrics as well as other social media tools such as Facebook and Google +. Please read my extensive review about this tool. This service is free.

Bit.ly

You should register with a domain shortening service such as bit.ly, which will provide you with an API key that you can enter into applications you use to share links. This will provide a means to keep track of your click-through statistics in one location. Bit.ly records how many times a link you created was clicked on, the referrer and location of the user. Consider registering your own domain name and using it to shorten your tweets as a means of branding. In addition, you can use your custom link on electronic copies of your CV or at your own web site. This will inform you when your links have been clicked on. You should also consider using bit.ly to create links used at your web site, providing you with feedback on which are used the most often. For example, all of the links in this article were created using my custom bit.ly domain. In addition, you can tweet a link to any research study you publish to publicize as well as keep track of how many clicks are obtained. Bit.ly is a free service.

TweetReach

Another tool to measure your tweets is TweetReach. This service allows you to track the reach of your tweets by Twitter handle or tweet. It provides output in formats that can be saved for use elsewhere (Excel, PDF or the option to print or save your output by link). To use these latter features you must sign up for an account but the service is free.

Buffer

Buffer is a tool that allows you to schedule your tweets in advance. You can also connect Buffer to your bit.ly account so links used can be included in your overall analytics. Although Buffer provides its own measures on click-through counts this can contradict what appears in bit.ly. This service is free but also has paid upgrade options available that provide more detailed analytics.

Web presence

Google Scholar Citation Profile

You can set up a profile with Google Scholar based on your publication record. The metrics provided by this service include a citation count, h-index and i10-index. When someone searches your name using Google Scholar your profile will appear at the top before any of the citations. This provides a quick way to separate your articles from someone else who has the same name as you.

Google Feedburner for RSS feeds

If you maintain your own web site and use RSS feeds to announce new postings you can also collect statistics on how many times your article is clicked on. Feedburner, recently acquired by Google provides one way to measure this. You enter your RSS feed ULR and a report is generate, which can be saved in CVS format.

Journal article download statistics

Many journals provide statistics on the number of downloads of articles. Keep track of those associated with your publication by visiting the site. For example, BioMed Central (BMC) maintains an access count of the last 30 days, one year and all time for each of your publications.

Quora

Other means of contributing to the knowledge base in your field include participating on web-based forums or web sites such as Quora. Quora provides threaded discussions on topics and allows participants to both generate and respond to the question. Other users vote on your responses and points are accrued. If you want another user to answer your question you must “spend” some of your points. Providing a link to your public profile on Quora on your CV will demonstrate another form of contribution to your field.

Paper.li

Paper.li is a free service that curates content and renders it in a web-based format. The focus of my Paper.li is the use of technology in Canadian Healthcare. I have also created a page that appears at my web site. Metrics on the number of times your paper has been shared via Facebook, Twitter, Google + and Linked are available. This service is free.

Twylah

Twylah is similar to paper.li in that it takes content and displays it in a newspaper format except it uses your Twitter feed. There is an option to create a personalized page. I use tweets.lauraogrady.ca. I also have a Twylah widget at my web site that shows my trending tweets in a condensed magazine layout. It appears in the side bar. This free service does not yet provide metrics but can help increase your tweet reach. If you create a custom link for your Twylah page you can keep track of how many people visit it.

Analytics for your web site

Log file analysis

If you maintain your own web site you can use a variety of tools to capture and analyze its use. One of the most popular applications is Google Analytics. If you are using a content management system such as WordPress there are many plug-ins that will add the code to the pages at your site and produce reports. WordPress also provides a built-in analytic available through its dashboard.

If you have access to the raw log files you could use a shareware log file program or the open source tool Piwik. These tools will provide summaries about what pages of your site are visited most frequently, what countries the visitors come from, how long visitors remain at your site and what search terms are used to reach your site.

Summary

All of this information should be included in the annual report you prepare for your department and your tenure application. This will increase awareness of altmetrics and improve our ability to have these efforts “count” as contributions in your field.

June 24,2012

12:52
  1. The following provides a timeline of articles that appeared in newspapers and blogs from January 2011 to present. The articles demonstrate a progress from patient engagement in online communities to those that include reference to increasing provider involvement.
  2. January 5th, 2011
  3. February 3rd, 2011
  4. February 22nd, 2011
  5. March 23rd, 2011
  6. April 2nd, 2011
  7. April 25th, 2011
  8. May 14th, 2011

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